Excited Delirium: Deadly for Patients Dangerous for Providers Sean Kivlehan September 2017 (example) • https://www.youtube.com/watch?v=Ai2bVK_BGHs Definition Complications Pathophysiology Differential Recognition Treatment What is ExDS? Delirium: acute and temporary change in cognition and mental status Excited: uncontrollable and violent behavior Syndrome: a cluster of signs and symptoms commonly seen together and thought to have the same underlying cause This wasn’t in my textbook… “agitated delirium” Not Without Controversy… Pathophysiology 1. Drug use: cocaine, methamphetamines, PCP, LSD, bath salts, K2 2. Psychiatric illness: schizophrenia & bipolar 3. Abrupt cessation of psych meds Dopamine Schizophrenia? Schizophrenia meds block Dopamine Recognizing the patient Recognizing the complications Metabolic Acidosis Rhabdomyolysis Sudden Death Secondary Trauma Metabolic Acidosis • Sympathomimetic & agitated need to blow off CO2 • Cant do this if restrained improperly • CO2 builds respiratory acidosis • Lactic acidosis occurs eventually Rhabdomyolysis • Muscle breakdown • Restraints & Fighting • Acute Kidney Injury • Hyperkalemia • Hypovolemia Sudden Death Likely combination of several factors: • Positional asphyxiation • Cardiotoxicity from the drugs • Long QT • Cardiac sensitivity (acidosis & hyperK) Secondary Trauma • Before the encounter • During the restraint Full trauma survey always Differential • Hypoxia • Anticholinergic Toxidrome • Hypoglycemia • Neuroleptic Malignant • Head Trauma Syndrome (NMS) • Infection • Serotonin Syndrome • Epilepsy • Thyroid Storm • Heat Stroke Treatment Scene Safety is most important • Protect responders • Protect patient • Protect bystanders “Dual Response” • train together • have a plan Verbal Deescalation • Reduce L&S if possible • Calm patient, one provider, try to develop rapport Prepare for plan b from beginning Physical Restraints Plan & prepare • One extremity per provider, • One to head, • One to stretcher, • One to help w/ restraints Soft restraints (PIC) Restraint NEVERS • Hog tie • Prone • Chest or neck compression Sedation • As soon as possible, with restraints is possible • Better than restraints & safer • Pros & Cons of approach – • IV more predictable but needle stick risk & losing IV • IM less predictable, slower onset but safer, easier access • IN has bite risk but is needleless Sedation Options Benzos – Midazolam, Diazepam, Lorazapam • Slower onset, long half life (stacking risk), resp depression Ketamine – dissociative anesthetic • Multiple uses, protects airway but can cause vomiting • Other SEs are tachycardia, hypertension, laryngospasm, hypersalivation • Cannot use in schizophrenics Once sedated & safe, now treat the complications Hyperthermia cool patient Hypovolemia fluid resus Acidosis bicarb Rhabdomyolysis fluids & bicarb Full secondary survey trauma from earlier or during restraints Monitor airway visible at all times, pulseox or capnography [email protected].